-To be aware of the challenges facing the future of emergency nursing in the UK.

What is emergency nursing?

Emergency nursing involves the episodic care of people with physical and / or psychological health problems. These health problems: (1) may result from injury and / or illness, (2) are usually acute, and (3) require further, often immediate, investigation and / or intervention. Emergency nurses care for people of all ages, and work with conditions which may affect any - or, indeed, all - of the body's systems. Often (though not always), patients requiring emergency care are physiologically (or psychologically) unstable, have complex health and other needs, and require intensive nursing care. As with all nursing care, emergency nursing care is provided in a way that is patient centred - that is, focused on the individual patient and their unique needs, wants and preferences.

Emergency nursing care may be delivered in a variety of settings - including in accident and emergency (A&E) departments, minor injury units, ambulance or other acute transport services, out-of-hours walk-in centres and in the armed forces. These settings usually allow for the unplanned or unscheduled presentation of a patient, often without prior warning, either via self-referral or referral from another service. In emergency settings, care is often provided on an 'as-needed' basis - usually outside regular working hours, and often continually 24 hours per day, 7 days per week.

As with general nursing, emergency nurses work within the assessment  planning  intervention  evaluation (APIE) framework. The emergency nurse's role includes a range of general nursing tasks, such as rapid patient assessment, making accurate diagnoses, allocating priorities for care, delivering treatment interventions, monitoring and evaluating care, and facilitating discharge and referral. However, because they work with diverse populations and manage a variety of different disease processes, emergency nurses must also possess a range of specialist nursing skills. These specialist skills include the ability to comprehensively assess patients, to effectively resuscitate and provide life-sustaining care to patients, to apply sound clinical judgement to diagnose and manage a range of traumatic injuries and serious physical / psychological illnesses, to practice effectively in large interdisciplinary care teams, and to engage positively with the public in what is often a stressful and emotionally-charged environment.

The emergency nursing context

As noted earlier, emergency nurses must be able to effectively care for diverse populations. In the UK, the four most likely groups to present to A&E Departments are people aged >90 years, people aged 80-89 years, people aged 20-29 years, and people aged 0-9 years. In younger age-groups (<29 years), women are more likely than men to present to an A&E Department; however, in older age-groups (>35 years), men are slightly more likely than women to present. The ability to communicate with, assess and provide treatment to paediatric, adolescent, adult and elderly populations, and people of all genders, is clearly a fundamental skill for emergency nurses!

Also highlighted earlier, emergency care services in the UK are often provided outside regular working hours, and sometimes continually on a 24/7 basis. Statistics compiled by the National Health Service (NHS) suggest that the two busiest days in terms of A&E attendance are, interestingly, Mondays and Sundays. Most people attend A&E Departments during business hours, between 9am and 6pm; generally, the busiest attendance time is 11am, though ambulance arrivals at A&E Departments tend to peak at 3pm, and the quietest time is 5am. People tend to present to A&E Departments for different reasons at different times across the week; for example, presentations for injuries due to road traffic accidents are highest at 6pm on weekdays, and presentations for assault are highest during the early hours of Sundays. Regardless of the shift onto which an emergency nurse is rostered, they will encounter a diverse and challenging practice environment.

People may present to A&E for a wide variety of reasons - consider the following common examples:

Statistics compiled by the NHS suggests that around 13% of people who attend an A&E Department are discharged without requiring any treatment, and another 35% receive advice and / or guidance only. However, this does not mean that these patients are attending A&E Departments unnecessarily, nor that they could be cared for in other settings. Indeed, there are a number of important reasons why people in the UK may present to A&E Departments for relatively minor complaints.

One key reason is the lack of general practitioner (GP) appointments available in the UK; indeed, the most recent UK GP Patient Survey suggests that 15% of patients requiring a GP appointment were unable to book one, and around 4% of these patients presented to an A&E Department instead. Confusion about the UK's complex healthcare system, particularly in relation to the services providing out-of-hours care, may be another reason that people present to A&E Departments for relatively minor complaints.

It is also important for nurses to be aware of the ever-changing context in which they practice. In the UK, there have been a number of recent, and relatively major, policy shifts in relation to the delivery of emergency services. In particular, there has been a rapid expansion of nurse-led emergency services, such as minor injury units, which require emergency nurses to practice in a largely autonomous capacity. The emergency nurse's role has expanded, and nurse practitioners are now often responsible for leading the triage of patients in tertiary emergency care settings. The development of protocols relevant to the emergency care context - most notably, for the management of traumatic injury - have been implemented in an attempt to improve the efficiency and cost-effectiveness of the delivery of emergency care. If you practice as an emergency nurse, it is important that you remain abreast of the changes in the specialty, and that you are aware of how these changes affect you, your patients and your practice.

Identifies expected outcomes, and evaluates the care provided against these.

Proactively modifies plans of care to ensure it continually meets a patient's needs.

Recognises their learning needs, and engages in professional development.

Ensures open and timely communication with patients, families and other staff.

Provides care which is patient-centred and collaborative, wherever possible.

Adheres to accepted, established and relevant practice standards and legislation.

Engages, at all times, in professional activities and behaviours.

Values life, dignity, worth, autonomy and individuality, etc.

Legal and ethical considerations

Consent: Consent is the agreement of a patient to submit to proposed investigation or treatment. Although it is a fundamental requirement in all nursing settings, consent is a particularly important consideration in the emergency nursing context where the care provided is often fast-paced, and may progress with little direct patient involvement. Consent may be provided in written, verbal or non-verbal form. Once given, consent applies indefinitely; however, it may also be refused or withdrawn at any time, if a patient considers this in their best interest - even if this places their wellbeing at risk. In the emergency nursing context, seeking consent can be thought of as a 'process'; nurses should continually seek the consent of patients to provide investigation and / or treatment, rather than during a single event. For consent to be valid, or legally sound, "it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question" (Department of Health, 2009: p. 9).

As an emergency nurse, you may frequently deal with patients who are unconscious. It is important, therefore, to make a note about consent in unconscious patients. If a patient is unconscious, it is assumed that - in most situations - as a mentally competent person they would wish for all appropriate measures to sustain life and promote wellbeing to be taken by the professionals involved in their care. However, in some cases (particularly in patients who are palliated), advance decisions may be made to refuse life-sustaining measures, such as resuscitation; in these situations, the decision to refuse consent will be formally documented.

Duty of care: Duty of care is owed by a nurse to any person - and particularly patients - who may be affected by their actions, advice or admissions. A breach of duty of care occurs when a nurse fails to do what a 'reasonable' person would do in a similar situation, or does what a 'reasonable' person would not do. The standard of care expected is that of a nurse with an average level of skills, knowledge and experience. To maintain your duty of care, you must practice within your scope. Essentially, this means you must provide care consistent with your own skills, knowledge and experience, and not beyond what you have learned in your training and become qualified to administer. It is important to highlight that nurses working in emergency care settings come from a variety of professional backgrounds and, therefore, have diverse skills, knowledge and experience. Furthermore, an emergency nurse's scope of practice may be impacted by factors such as the type of emergency care setting in which they practice (including the degree of autonomy they are afforded), and the region in which they are located. A nurse may be found legally negligent if they work outside their scope of practice, breach their duty of care, and cause damage to the patient (e.g. injury or loss). To avoid breaching your duty of care and practicing negligently, you must be familiar with, and work within, your own scope of practice at all times.

Restraint: Restraint - that is, restricting a patient's movement, with the intention of protecting their own and / or others' safety - can be used in managing patients who are violent or aggressive, and particularly those who are mentally ill, intoxicated or otherwise incapacitated. There are two types of restraint: (1) physical restraint, or the restriction of movement by physical or mechanical means, and (2) chemical restraint, usually via the administration of sedative medication. Although there is a movement away from restraint in healthcare settings in the UK, it is essential that you are familiar with your organisation's policies and procedures for the appropriate use of restraint.

Privacy and confidentiality: Maintaining the right of patients to privacy and confidentiality is a requirement in all general practice settings, but is particularly important for nurses working in busy and fast-paced emergency settings. It is crucial that nurses working in emergency care settings understand with whom, and under what circumstances, they are permitted to share a patient's confidential information. Nurses must also ensure they are familiar with their organisation's systems for the collection, recording and storage of a patient's confidential information in the busy, fast-paced emergency care settings.

Conclusion

This chapter has provided a broad introduction to emergency nursing as a practice speciality in the UK. It has introduced emergency nursing as a diverse and complex practice specialty; one which requires nurses to work with a variety of patients, manage various clinical conditions, and practice in a range of different settings. It has also analysed some of the complex legal and ethical issues relevant to practice in an emergency care setting, and discussed the key challenges in the future of emergency care nursing in the UK.